PERSONAL INFORMATION

FULL NAME:                                                                        DATE:                                    

ADDRESS:                                                                            CITY:                                      STATE:                   ZIP:                     
PHONE:                                                 EMAIL ADDRESS:                                                                            
MARITAL STATUS:                            SEX:                      AGE:                    DATE OF BIRTH:                              
NUMBER OF CHILDREN:                  OCCUPATION:                                                                                  
NAME OF SPOUSE:                                                            SPOUSE'S OCCUPATION:                                                               

EMERGENCY NOTIFICATION

NAME:                                                                                  TELEPHONE:                                     

ADDRESS:                                                                           CITY:                                      STATE:                   ZIP:                     
REFERRED BY:                                                                 

CURRENT HEALTH CONDITION

PURPOSE OF THIS APPOINTMENT:                                                                                                                        

HOW DID IT HAPPEN?                                                                                                                                           
TODAY’S CONDITION STARTED WHEN?                                                                                                                
WHAT ACTIVITIES AGGRAVATE YOUR CONDITION?                                                                                             
WHAT ACTIVITIES LESSEN YOUR CONDITION?                                                                                                     
IS CONDITION WORSE DURING CERTAIN TIMES OF THE DAY?                                                                              
IS THIS CONDITION INTERFERING WITH WORK?                                 SLEEP?                               ROUTINE?                          
IS CONDITION GETTING PROGRESSIVELY WORSE?                                                                                                                      
OTHER DOCTORS SEEN FOR THIS CONDITION:                                                                                                                              
TYPE OF TREATMENT:                                                                              RESULTS:                                                                          

Habits
❑ Alcohol: Type:                  Difficulty falling asleep?            
Amount:                  Continuity disturbances?             ❑ Exercise routine:                        
Diet: Salt intake:                  Early morning awakenings?                                                            
Fat intake:                  Daytime drowsiness?                                                             
Other:                  Other:                                                             
                                                
❑ Sleep: number of hours/day (average): ❑ Smoking: Packs daily?            
                  How long?             ❑ Caffeine:               
Interested in stopping?            Coffee, cups daily:               
Other:               

Height:                  Blood Pressure (average):                   

Weight:                  Heart Rate (average):                   
Typical Diet:

Breakfast:
                                                                                                                                                                                                          
                                                                                                                                                                                                          
                                                                                                                                                                                                       

Lunch:
                                                                                                                                                                                                          
                                                                                                                                                                                                          
                                                                                                                                                                                                       

Dinner:
                                                                                                                                                                                                          
                                                                                                                                                                                                          
                                                                                                                                                                                                       

Snacks/other:
                                                                                                                                                                                                          
                                                                                                                                                                                                        

Fluids (please specify amount if possible):

                                                                                                                                                                                                          
                                                                                                                                                                                                        

MEDICATIONS:
                                                                                                                                                                                                          
                                                                                                                                                                                                          
                                                                                                                                                                                                       

SUPPLEMENTS:
                                                                                                                                                                                                          
                                                                                                                                                                                                          
                                                                                                                                                                                                       

ALLERGIES (drug/food/other) please specify your reaction to the substance:

                                                                                                                                                                                                          
                                                                                                                                                                                                        
Medical History
(To fill-in digitally, delete the square to the left of the chosen condition; then right-click to the left of the chosen words, scroll
up to “bullets” and select the bullet shaped like a check mark. Repeat this process for each pertinent square as needed.)

 RINGING IN EAR  GALL BLADDER TROUBLE  TREMOR / HANDS SHAKING

 MEASLES
 EAR INFECTIONS -  JAUNDICE/HEPATITIS  MUSCLE WEAKNESS  RUBELLA
FREQUENT  RHEUMATIC FEVER
 SCARLET FEVER
 TUBERCULOSIS
 DIZZINESS / FAINTING  CHANGE IN BOWEL HABITS  NUMBNESS / TINGLING
 HERPES
SENSATIONS
 OTHER (PLEASE SPECIFY)

 FAILING VISION  DIARRHEA  HEADACHES - FREQUENT

 CONSTIPATION

 EYE INFECTIONS  DIVERTICULOSIS  ARTHRITIS / RHEUMATISM  FEMALES -PLEASE COMPLETE

 CROHN'S / COLITIS

 NOSE BLEEDS  BLOODY OR TARRY STOOLS ❏ OSTEOPOROSIS PREGNANT?

 YES
 NO

 SINUS TROUBLE  HEMORRHOIDS  BACK PAIN - RECURRENT PLANNING PREGNANCY?

 YES
 NO

 SORE THROATS -  HERNIA  BONE FRACTURE / JOINT

FREQUENT INJURY MENSTRUAL FLOW:
 REGULAR
 HAYFEVER / ALLERGIES  URINE INFECTIONS - FREQUENT  GOUT  IRREGULAR
 PAIN / CRAMPS
 PNEUMONIA  BLOOD IN URINE  FOOT PAIN
 COLD NUMB FEET DAYS OF FLOW:
LENGTH OF CYCLE:
 BRONCHITIS / CHRONIC URINATION-  RASHES
COUGH  HIVES
❑ OVERNIGHT > THAN TWICE
 ASTHMA / WHEEZING  PSORIASIS DATE- 1ST DAY OF LAST PERIOD:
 ECZEMA
 PAINFUL

 CHEST PAIN  NERVOUSNESS  PAIN / BLEEDING DURING OR

 LOSS OF CONTROL  DEPRESSION AFTER SEX

 DECREASE IN FORCE/FLOW

 HIGH BLOOD PRESSURE  KIDNEY STONES  MEMORY LOSS NUMBER OF:

 PREGNANCIES:
 HEART MURMUR  VENEREAL DISEASE  MOODINESS - EXCESSIVE  ABORTIONS:
 MISCARRIAGES:
 LIVE BIRTHS:
 SWOLLEN ANKLES  URETHRAL DISCHARGE  PHOBIAS

 LEG PAIN - WALKING  CHRONIC FATIGUE  MENTAL ILLNESS ❏ BIRTH CONTROL METHOD:

 VARICOSE VEINS /  WEIGHT LOSS - RECENT  LACTOSE INTOLERANCE  B. C. PILL (NAME):

PHLEBITIS

 LOSS OF APPETITE  ANEMIA  PROSTATE DISEASE  FLUSHING / MENOPAUSE

 BRUISE EASILY

 DIFFICULTY  CANCER  SEXUAL / MENSTRUAL

SWALLOWING DYSFUNCTION DATE OF LAST PAP TEST:

 INDIGESTION OR  DIABETES  FREQUENT INFECTIONS  NORMAL

HEARTBURN  ABNORMAL

 PERSISTENT NAUSEA /  THYROID DISEASE  DIPHTHERIA

VOMITING DATE OF LAST MAMMOGRAM:

 PEPTIC ULCERS  CONVULSIONS / SEIZURES  TETANUS

 NORMAL
 ABNORMAL
 ABDOMINAL PAIN -  STROKE  CHICKEN POX
CHRONIC  POLIO
 MUMPS
 HOSPITALIZATIONS:

Date Reason Date Reason

FAMILY HISTORY

PLEASE GIVE THE FOLLOWING INFORMATION ABOUT YOUR IMMEDIATE FAMILY: HAVE ANY BLOOD RELATIVES HAD
THE FOLLOWING ILLNESSES? IF SO,
PLEASE INDICATE RELATIONSHIP:

RELATIONSHIP AGE IF LIVING AGE AT STATE OF HEALTH OR CAUSE OF ILLNESS FAMILY MEMBER
DEATH DEATH
FATHER DIABETES
MOTHER CANCER
BROTHERS AND _______________ ___________ ________________________________ BLOOD DISEASE __________________
SISTERS _______________ ___________ ________________________________ GLAUCOMA __________________
____________ ___________ _____________________________ EPILEPSY __________________

SPOUSE RHEUMATOID
ARTHRITIS
CHILDREN _______________ ___________ ________________________________ TUBERCULOSIS __________________
_______________ ___________ ________________________________ GOUT __________________
____________ ___________ _____________________________ HIGH BLOOD __________________
PRESSURE

HEART DISEASE
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